Acute stress reaction

Overview

Acute stress reaction (ASR) - a transient psychological response arising immediately after a severely threatening/horrific event. ICD-11 term; DSM-5 uses 'acute stress disorder'. Symptoms resolve within hours to ~4 weeks; beyond 4 weeks, reconsider PTSD or adjustment disorder.

Presentation

•Emotional - intense fear, horror, helplessness, grief, anger, guilt, or emotional numbing
•Cognitive - poor concentration, confusion, intrusive memories/flashbacks, dissociation
•Behavioural - avoidance of trauma-related stimuli, social withdrawal, agitation
•Somatic - palpitations, trembling, sweating, nausea (sympathetic activation)
•Sleep - insomnia and nightmares driven by hyperarousal
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Peritraumatic dissociation (depersonalisation, sense of unreality at time of trauma) is one of the strongest predictors of later PTSD development.

Management

First-line · Immediate
  1. 1Psychological first aid - ensure safety, practical support, psychoeducation about normal stress responses, facilitate social support. Avoid enforced debriefing.
First-line · Significant or persistent symptoms
  1. 1Trauma-focused cognitive behavioural therapy (TF-CBT) - helps process traumatic memory, challenge maladaptive cognitions, reduce avoidance
Second-line · If TF-CBT ineffective
  1. 1Sertraline (SSRI) - increases synaptic serotonin, regulates mood/anxiety/fear responses
Third-line · After CBT and SSRI have failed
  1. 1Moclobemide (reversible MAOI) - not a routine first or second option
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EMDR is NOT first-line for ASR - it is recommended for PTSD. In the acute phase, the structured reprocessing required by EMDR is inappropriate when the person is still in crisis. Classic exam distractor.

Follow-up

•Review at 4 weeks - if symptoms persist, reconsider diagnosis (PTSD, adjustment disorder, depressive episode)
•Screen high-risk groups (refugees, disaster survivors) at one month with a validated tool
•Refer to secondary care (psychiatry) if diagnostic uncertainty, severe functional impairment, significant self-harm risk, or failure to respond to first-line management